Background: Current prevalence of COVID-19 drives many policy decisions, but is hampered by ambig... more Background: Current prevalence of COVID-19 drives many policy decisions, but is hampered by ambiguities in testing and reporting. We propose an alternative method for estimating community prevalence that is inexpensive and timely. We test the Hypothesis that the survey sampling provides a quantitative prevalence that is similar to widespread genomic or serological testing. Methods: We have built a simple, web-based survey of signs and symptoms for COVID-19 based on six questions. No personally identifiable information is collected to maintain privacy. Sampling can be directed to a population of interest such as a company, or broadcast widely to get geographic sampling. Data reporting can be real-time and plotted onto zipcode maps. Rates of prevalence were calculated from presumed COVID cases and respondents, with confidence intervals based on the Blaker method.Results: The website was created quickly, and survey results were quantitatively useful after only a few days. Analyzing 316...
Results: 46 patients, enrolled from 2015 to 2020 were included. 27 (58.7%) were male. 18 patients... more Results: 46 patients, enrolled from 2015 to 2020 were included. 27 (58.7%) were male. 18 patients (39.1%) had a diagnosis of minimal change followed by focal segmental glomerulosclerosis in 16 patients (34.7%). Median age at start of treatment was 12.5 years (IQR 8.5-17.4) compared to 5.3 years at diagnosis (IQR 2.7-10.5 years). 52% were resistant to corticosteroids. The most common Acthar Gel regimen was 80IU twice a week with a median duration of 199 days (IQR 88365). Among 37 patients with active disease, 18 (49%) were able to achieve partial or complete remission, though all patients that had a positive response were on other immunosuppressants concomitantly.
Patients with cystic fibrosis (CF) develop chronic bacterial infections in the respiratory tract,... more Patients with cystic fibrosis (CF) develop chronic bacterial infections in the respiratory tract, reflecting dysfunctional innate immunity. Neutrophil gelatinase-associated lipocalin (NGAL) has 2 functions: one as an antibacterial host defense protein and the other as a physiological iron carrier. Neutrophil gelatinase-associated lipocalin (NGAL) has been validated as a biomarker for early kidney disease. The aim of this study was to determine whether NGAL could serve as a marker of acute pulmonary exacerbations in CF by measuring NGAL levels in serum samples from subjects with CF during stable clinic visits and during hospitalization for pulmonary exacerbations and comparing these levels to healthy controls and to patients without CF with significant infection. In addition, we aimed to determine if innate immunity cells other than neutrophils act as a source of NGAL. Circulating NGAL levels were measured by enzyme-linked immunosorbent assay in serum samples from 30 subjects with CF when hospitalized for an acute pulmonary exacerbation, 33 subjects with CF during stable clinic visits, 33 patients with sepsis, and 21 healthy controls. Secreted NGAL from CF and healthy control peripheral monocytes infected with Pseudomonas aeruginosa was also measured by enzyme-linked immunosorbent assay. Serum NGAL levels were elevated in the patients with CF compared to the healthy controls (P < 0.001). However, no difference in serum NGAL levels was found between subjects with CF with stable disease compared to subjects with CF undergoing pulmonary exacerbation. Furthermore, peripheral monocytes from CF and subjects without CF secreted NGAL upon infection with Pseudomonas aeruginosa and thereby may be contributing to the circulating NGAL levels observed. Our data show that peripheral monocytes secrete NGAL, and serum NGAL levels are widely distributed among subjects with CF, being elevated both when clinically stable and during a pulmonary exacerbation and thus NGAL is not a sensitive biomarker for pulmonary exacerbations.
Bleeding is a serious complication after pediatric cardiopulmonary bypass (CPB) that is associate... more Bleeding is a serious complication after pediatric cardiopulmonary bypass (CPB) that is associated with an increase in perioperative morbidity and mortality. Four-factor prothrombin complex concentrates (4F-PCCs) have been used off-label to supplement transfusion protocols for bleeding after CPB in adults; however, data on their use in neonates are limited. In this study, we hypothesized that 4F-PCCs administered ex vivo to neonatal plasma after CPB will increase thrombin generation. Fifteen neonates undergoing complex cardiac repairs requiring CPB were enrolled in this prospective study. Arterial blood was obtained after anesthesia induction but before CPB (baseline), after CPB following heparin reversal, and after our standardized transfusion of a quarter of a platelet apheresis unit (approximately 20 mL·kg) and 3 units of cryoprecipitate. Kcentra (CSL Behring), a 4F-PCC with nonactivated factor VII (FVII), and factor 8 inhibitor bypassing activity (FEIBA; Baxter Healthcare Corporation), a 4F-PCC with activated FVII, were added ex vivo to plasma obtained after CPB to yield concentrations of 0.1 and 0.3 IU·mL. Calibrated automated thrombography was used to determine thrombin generation for each sample. The addition of Kcentra to plasma obtained after CPB resulted in a dose-dependent increase in the median (99% confidence interval) peak amount of thrombin generation (42.0 [28.7-50.7] nM for Kcentra 0.1 IU·mL and 113.9 [99.0-142.1] nM for Kcentra 0.3 IU·mL). The rate of thrombin generation was also increased (15.4 [6.5-24.6] nM·min for Kcentra 0.1 IU·mL and 48.6 [29.9-66.6] nM·min for Kcentra 0.3 IU·mL). The same was true for FEIBA (increase in peak: 39.8 [27.5-49.2] nM for FEIBA 0.1 IU·mL and 104.6 [92.7-124.4] nM for FEIBA 0.3 IU·mL; increase in rate: 17.4 [7.4-28.8] nM·min FEIBA 0.1 IU·mL and 50.5 [26.7- 63.1] nM·min FEIBA 0.3 IU·mL). In the posttransfusion samples, there was a significant increase with Kcentra in the median (99% confidence interval) peak amount (41.1 [21.0-59.7] nM for Kcentra 0.1 IU·mL and 126.8 [106.6- 137.9] nM for Kcentra 0.3 IU·mL) and rate (18.1 [-6.2 to 29.2] nM·min for Kcentra 0.1 IU·mL and 53.2 [28.2-83.1] nM·min for Kcentra 0.3 IU·mL) of thrombin generation. Again, the results were similar for FEIBA (increase in peak: 43.0 [36.4-56.7] nM for FEIBA 0.1 IU·mL and 109.2 [90.3-136.1] nM for FEIBA 0.3 IU·mL; increase in rate: 25.0 [9.1-32.6] nM·min for FEIBA 0.1 IU·mL and 59.7 [38.5-68.7] nM·min for FEIBA 0.3 IU·mL). However, FEIBA produced in a greater median reduction in lag time of thrombin generation versus Kcentra in samples obtained after CPB (P = 0.003 and P = 0.0002 for FEIBA versus Kcentra at 0.1 and 0.3 IU·mL, respectively) and in samples obtained after transfusion (P < 0.0001 for FEIBA versus Kcentra at 0.1 and 0.3 IU·mL). After CPB, thrombin generation in neonatal plasma was augmented by the addition of 4F-PCCs. The peak amount and rate of thrombin generation were enhanced in all conditions, whereas the lag time was shortened more with FEIBA. Our findings suggest that the use of 4F-PCCs containing activated FVII may be an effective adjunct to the initial transfusion of platelets and cryoprecipitate to augment coagulation and control bleeding in neonates after CPB.
Purpose: To compare combination chemotherapy (CCT) versus melphalan plus prednisone (MP) as treat... more Purpose: To compare combination chemotherapy (CCT) versus melphalan plus prednisone (MP) as treatment for multiple myeloma. Patients and Methods: In a collaborative worldwide overview of randomized trials of CCT versus MP, individual patient data on 4,930 patients from 20 trials were analyzed, with the addition of published data on a further 1,703 patients from seven trials. The main outcome measure was mortality, with response and recurrence rates being subsidiary end points. Results: Taking all of the trials together, response rates were significantly higher with CCT than with MP (60.0% v 53.2%; P < .00001, two-tailed). There was no evidence of any difference in mortality between CCT and MP, with a nonsignificant 1.5% reduction in death rate in favor of CCT (P = .6, two-tailed). There is heterogeneity of design between the trials, but subgroup analyses by type of CCT or by dose-intensities of CCT, of melphalan, or of prednisone did not identify any particular forms of therapy t...
Introduction: Prior research on physician and non-physician endotracheal intubation (ETI) of pedi... more Introduction: Prior research on physician and non-physician endotracheal intubation (ETI) of pediatric patients demonstrates highly variable success rates. To assess the performance of a single children's critical care transport team (CCT), we analyzed data from 2.5 years of pediatric ETI encounters. Methods: A retrospective review encompassed pediatric ETI encounters from 127 patient charts from the rotorcraft and ground emergency CCT of a large quaternary referral children's hospital with an average of greater than 5000 patient transports annually. Pediatric patients were cared for by the CCT between January 1, 2011, and July 31, 2013. We included all patients between 1 day and 20 years of age in our analysis, without exclusion. A single ETI attempt was defined by the insertion of a laryngoscope. We characterized first-attempt intubation success and overall intubation success with descriptive statistics and calculated 95% confidence intervals. Results: For our cohort, demo...
Background: African-American youth carry the highest burden of HIV-infection in the US. Understan... more Background: African-American youth carry the highest burden of HIV-infection in the US. Understanding adolescent and young adult (AYA) perspectives on HIV transmission risk may serve as an important framework for targeted interventions and improved access. Methods: We conducted exploratory qualitative focus groups and quantitative surveys with HIV-infected and uninfected youth, ages 18-24 years, from Metropolitan Atlanta. Audio Computer-Assisted Self-Interviewing surveys gauged potential risk factors for HIV acquisition using categorical, and Likert scale (LS) responses (1-10). We examined perceptions regarding HIV-education and contributors to HIV-transmission. Results: Of 68 participants, 85% were male, 90% were African-American, 68% were HIV-infected, and 50% had high school education or less. Participants had a mean age of 21.5 years (SD: 1.8 years). Risk factors for HIV acquisition included high rates of unprotected sex (LS mean: 8.0) with personal preference (63%) and fear of ...
Background: Half of the 19 million new sexually-transmitted infections (STIs) and 26% of all new ... more Background: Half of the 19 million new sexually-transmitted infections (STIs) and 26% of all new HIV infections each year in the United States occur in youth 13-24 years of age. Co-STIs are a risk factor for HIV acquisition and transmission, but there are a lack of data to assess treatment and virologic control of HIV as an intervention for reducing STI transmission. Methods: This was a single-centered, retrospective analysis of HIV-infected sexually-active adolescents and young adults from January 2009 to December 2011, designed to compare incidence of STIs among patients with controlled and uncontrolled HIV and identify associated risk factors. Controlled HIV infection was defined as a 2-year mean HIV-RNA viral load of <500 copies/ml and CD4+ T-cell count >200 cells/mm3. Socio-demographic, sexual history, substance abuse and HIV variables were evaluated. Results: Of the 206 enrolled subjects, 59% were male and 92% were African American with a mean age of 21 years (2.1 SD). 6...
We reviewed the records of 98 consecutive patients, 18 years of age or younger, with pathological... more We reviewed the records of 98 consecutive patients, 18 years of age or younger, with pathologically confirmed supratentorial astroglial neoplasms at the Children&amp;amp;amp;amp;#39;s Hospital, Boston, to evaluate the importance of seizures in their presentation and natural history. Tumors were diagnosed using the WHO criteria as pilocytic astrocytomas, astrocytomas, anaplastic astrocytomas, glioblastomas, giant cell glioblastomas, oligoastrocytomas and gangliogliomas. Our results were as follows. (1) Fifty percent of children had seizures as part of their presentation and 30% had seizures as their only presenting phenomenon. (2) The seizures varied in nature, but complex (55%) or simple (28%) partial seizures were by far the most common types, occurring in 77% of cases. (3) Preoperative electroencephalography (EEG) accurately lateralized to the tumor side in 88% of the cases and localized to the correct lobe in 56%. (4) Tumors involving cerebral cortex significantly correlated with seizures at presentation as compared to noncortical locations; 59% of patients with cortical tumors presented with seizures, and only 15% of patients with noncortical tumors experienced seizures. Lesions in the temporal and frontal lobes had the highest incidence of seizures. (5) Patients with gangliogliomas and oligoastrocytomas had the highest incidence of seizures, 88 and 86%, respectively, whereas patients with anaplastic astrocytoma had the lowest incidence, 21%. (6) Histopathologic calcification was associated with seizures at presentation approaching significance (p = 0.06). (7) Seizures at presentation were significantly associated with good prognosis (p = 0.02).
Thirty-three evaluable patients with Hodgkin&amp;amp;#39;s disease who failed radiotherapy we... more Thirty-three evaluable patients with Hodgkin&amp;amp;#39;s disease who failed radiotherapy were treated on this phase II study with bleomycin, lomustine, cyclophosphamide, vincristine, procarbazine and prednisone given every 28 days for a minimum of eight courses. Twenty-five patients (76%; 95% CI=55.6-87.1%) achieved a complete remission, the median duration of which cannot yet be determined, but the probability of remaining in continuous complete remission at 10 years is.64. The median survival from entry on this study for all evaluable patients is 10 years, and 12 patients were alive at the time of this analysis with a median follow-up for them of 15.5 years. Of the 22 patients who died, 11 died of progressive or recurrent Hodgkin&amp;amp;#39;s disease and 11 died of other causes including 7 second primary neoplasms and at least one myocardial infarction. Both are now well known late complications of Hodgkin&amp;amp;#39;s disease treatment.
Adrenal insufficiency may be common in adults and children with vasopressor-resistant shock. We d... more Adrenal insufficiency may be common in adults and children with vasopressor-resistant shock. We developed a protocolized approach to low-dose adrenocorticotropin testing and empirical low-dose glucocorticoid/mineralocorticoid supplementation in children with systemic inflammatory response syndrome and persistent hypotension following fluid resuscitation and vasopressor infusion. We hypothesized that absolute and relative adrenal insufficiency was common in children with systemic inflammatory response syndrome requiring vasopressor support and that steroid administration would be associated with decreased vasopressor need. Retrospective review of pediatric patients with systemic inflammatory response syndrome and vasopressor-dependent shock receiving protocol-based adrenocorticotropin testing and low-dose steroid supplementation. The incidence of absolute and relative adrenal insufficiency was determined using several definitions. Vasopressor dose requirements were evaluated before, and following, initiation of corticosteroids. Seventy-eight patients met inclusion criteria for systemic inflammatory response syndrome and shock; 40 had septic shock. Median age was 84 months (range, 0.5-295). By adrenocorticotropin testing, 44 (56%) had absolute adrenal insufficiency, 39 (50%) had relative adrenal insufficiency, and 69 (88%) had either form of adrenal insufficiency. Adrenal insufficiency incidence was significantly higher in children &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;2 yrs (p = .0209). Therapeutic interventions included median 80-mL/kg fluid resuscitation; 65% of patients required dopamine, 58% norepinephrine, and 49% dopamine plus norepinephrine. With steroid supplementation, median dopamine dose decreased from 10 to 4 μg/kg/min at 4 hrs (p = .0001), and median dose of norepinephrine decreased from 0.175 μg/kg/min to 0.05 μg/kg/min at 4 hrs (p = .039). Absolute and relative adrenal insufficiency was prevalent in this cohort of children with systemic inflammatory response syndrome and vasopressor-dependent shock and increased with age. Introduction of steroids produced a significant reduction in vasopressor duration and dosage. Use of low-dose adrenocorticotropin testing may help further delineate populations who require steroid supplementation.
Mechanoreceptor and noxious thermal inhibitory stimulation modulate pain conduction but have not ... more Mechanoreceptor and noxious thermal inhibitory stimulation modulate pain conduction but have not been clinically tested in combination. Our objectives were to determine whether a vibrating cold device decreased adult venipuncture pain on a 10 cm visual analog scale more than no intervention, and compared with vapocoolant analgesia versus no intervention. The design was a prospective randomized crossover clinical trial. Thirty healthy adult volunteers were randomized to the study device or vapocoolant intervention. One nurse attempted cannulation on both intervention and control hands with a 22 gauge intravenous catheter. Vapocoolant was applied to the cannulation site, or the device was applied 5 to 10 cm proximally throughout the intervention attempt. Visual analog scale assessed needle fear and the primary outcome of self-reported pain. Sixteen device and 14 vapocoolant participants were included in this study. One participant felt discomfort from device prongs before the needle stick and was excluded. Compared with no intervention, the device reduced pain significantly (mean 9.9 mm, 95% confidence interval 0.82-19, P=0.035, SD 16) whereas vapocoolant did not (mean 7.9 mm, 95% confidence interval -1.8-17.7, P=0.1, SD 16.9). Mean pain reduction for device group participants was not significantly different from vapocoolant participants. Each 20 mm of prior anxiety increased the likelihood of intervention pain relief (odds ratio 2, P=0.043). One venipuncture failure occurred in the vapocoolant intervention. The combination of cold and vibration gave significant venipuncture pain relief without affecting cannulation success. Interventions were more helpful for those with greater preprocedural fear. Larger sample sizes and a prongless device could better compare equivalence or superiority to existing pain relief modalities.
Background: Current prevalence of COVID-19 drives many policy decisions, but is hampered by ambig... more Background: Current prevalence of COVID-19 drives many policy decisions, but is hampered by ambiguities in testing and reporting. We propose an alternative method for estimating community prevalence that is inexpensive and timely. We test the Hypothesis that the survey sampling provides a quantitative prevalence that is similar to widespread genomic or serological testing. Methods: We have built a simple, web-based survey of signs and symptoms for COVID-19 based on six questions. No personally identifiable information is collected to maintain privacy. Sampling can be directed to a population of interest such as a company, or broadcast widely to get geographic sampling. Data reporting can be real-time and plotted onto zipcode maps. Rates of prevalence were calculated from presumed COVID cases and respondents, with confidence intervals based on the Blaker method.Results: The website was created quickly, and survey results were quantitatively useful after only a few days. Analyzing 316...
Results: 46 patients, enrolled from 2015 to 2020 were included. 27 (58.7%) were male. 18 patients... more Results: 46 patients, enrolled from 2015 to 2020 were included. 27 (58.7%) were male. 18 patients (39.1%) had a diagnosis of minimal change followed by focal segmental glomerulosclerosis in 16 patients (34.7%). Median age at start of treatment was 12.5 years (IQR 8.5-17.4) compared to 5.3 years at diagnosis (IQR 2.7-10.5 years). 52% were resistant to corticosteroids. The most common Acthar Gel regimen was 80IU twice a week with a median duration of 199 days (IQR 88365). Among 37 patients with active disease, 18 (49%) were able to achieve partial or complete remission, though all patients that had a positive response were on other immunosuppressants concomitantly.
Patients with cystic fibrosis (CF) develop chronic bacterial infections in the respiratory tract,... more Patients with cystic fibrosis (CF) develop chronic bacterial infections in the respiratory tract, reflecting dysfunctional innate immunity. Neutrophil gelatinase-associated lipocalin (NGAL) has 2 functions: one as an antibacterial host defense protein and the other as a physiological iron carrier. Neutrophil gelatinase-associated lipocalin (NGAL) has been validated as a biomarker for early kidney disease. The aim of this study was to determine whether NGAL could serve as a marker of acute pulmonary exacerbations in CF by measuring NGAL levels in serum samples from subjects with CF during stable clinic visits and during hospitalization for pulmonary exacerbations and comparing these levels to healthy controls and to patients without CF with significant infection. In addition, we aimed to determine if innate immunity cells other than neutrophils act as a source of NGAL. Circulating NGAL levels were measured by enzyme-linked immunosorbent assay in serum samples from 30 subjects with CF when hospitalized for an acute pulmonary exacerbation, 33 subjects with CF during stable clinic visits, 33 patients with sepsis, and 21 healthy controls. Secreted NGAL from CF and healthy control peripheral monocytes infected with Pseudomonas aeruginosa was also measured by enzyme-linked immunosorbent assay. Serum NGAL levels were elevated in the patients with CF compared to the healthy controls (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001). However, no difference in serum NGAL levels was found between subjects with CF with stable disease compared to subjects with CF undergoing pulmonary exacerbation. Furthermore, peripheral monocytes from CF and subjects without CF secreted NGAL upon infection with Pseudomonas aeruginosa and thereby may be contributing to the circulating NGAL levels observed. Our data show that peripheral monocytes secrete NGAL, and serum NGAL levels are widely distributed among subjects with CF, being elevated both when clinically stable and during a pulmonary exacerbation and thus NGAL is not a sensitive biomarker for pulmonary exacerbations.
Bleeding is a serious complication after pediatric cardiopulmonary bypass (CPB) that is associate... more Bleeding is a serious complication after pediatric cardiopulmonary bypass (CPB) that is associated with an increase in perioperative morbidity and mortality. Four-factor prothrombin complex concentrates (4F-PCCs) have been used off-label to supplement transfusion protocols for bleeding after CPB in adults; however, data on their use in neonates are limited. In this study, we hypothesized that 4F-PCCs administered ex vivo to neonatal plasma after CPB will increase thrombin generation. Fifteen neonates undergoing complex cardiac repairs requiring CPB were enrolled in this prospective study. Arterial blood was obtained after anesthesia induction but before CPB (baseline), after CPB following heparin reversal, and after our standardized transfusion of a quarter of a platelet apheresis unit (approximately 20 mL·kg) and 3 units of cryoprecipitate. Kcentra (CSL Behring), a 4F-PCC with nonactivated factor VII (FVII), and factor 8 inhibitor bypassing activity (FEIBA; Baxter Healthcare Corporation), a 4F-PCC with activated FVII, were added ex vivo to plasma obtained after CPB to yield concentrations of 0.1 and 0.3 IU·mL. Calibrated automated thrombography was used to determine thrombin generation for each sample. The addition of Kcentra to plasma obtained after CPB resulted in a dose-dependent increase in the median (99% confidence interval) peak amount of thrombin generation (42.0 [28.7-50.7] nM for Kcentra 0.1 IU·mL and 113.9 [99.0-142.1] nM for Kcentra 0.3 IU·mL). The rate of thrombin generation was also increased (15.4 [6.5-24.6] nM·min for Kcentra 0.1 IU·mL and 48.6 [29.9-66.6] nM·min for Kcentra 0.3 IU·mL). The same was true for FEIBA (increase in peak: 39.8 [27.5-49.2] nM for FEIBA 0.1 IU·mL and 104.6 [92.7-124.4] nM for FEIBA 0.3 IU·mL; increase in rate: 17.4 [7.4-28.8] nM·min FEIBA 0.1 IU·mL and 50.5 [26.7- 63.1] nM·min FEIBA 0.3 IU·mL). In the posttransfusion samples, there was a significant increase with Kcentra in the median (99% confidence interval) peak amount (41.1 [21.0-59.7] nM for Kcentra 0.1 IU·mL and 126.8 [106.6- 137.9] nM for Kcentra 0.3 IU·mL) and rate (18.1 [-6.2 to 29.2] nM·min for Kcentra 0.1 IU·mL and 53.2 [28.2-83.1] nM·min for Kcentra 0.3 IU·mL) of thrombin generation. Again, the results were similar for FEIBA (increase in peak: 43.0 [36.4-56.7] nM for FEIBA 0.1 IU·mL and 109.2 [90.3-136.1] nM for FEIBA 0.3 IU·mL; increase in rate: 25.0 [9.1-32.6] nM·min for FEIBA 0.1 IU·mL and 59.7 [38.5-68.7] nM·min for FEIBA 0.3 IU·mL). However, FEIBA produced in a greater median reduction in lag time of thrombin generation versus Kcentra in samples obtained after CPB (P = 0.003 and P = 0.0002 for FEIBA versus Kcentra at 0.1 and 0.3 IU·mL, respectively) and in samples obtained after transfusion (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001 for FEIBA versus Kcentra at 0.1 and 0.3 IU·mL). After CPB, thrombin generation in neonatal plasma was augmented by the addition of 4F-PCCs. The peak amount and rate of thrombin generation were enhanced in all conditions, whereas the lag time was shortened more with FEIBA. Our findings suggest that the use of 4F-PCCs containing activated FVII may be an effective adjunct to the initial transfusion of platelets and cryoprecipitate to augment coagulation and control bleeding in neonates after CPB.
Purpose: To compare combination chemotherapy (CCT) versus melphalan plus prednisone (MP) as treat... more Purpose: To compare combination chemotherapy (CCT) versus melphalan plus prednisone (MP) as treatment for multiple myeloma. Patients and Methods: In a collaborative worldwide overview of randomized trials of CCT versus MP, individual patient data on 4,930 patients from 20 trials were analyzed, with the addition of published data on a further 1,703 patients from seven trials. The main outcome measure was mortality, with response and recurrence rates being subsidiary end points. Results: Taking all of the trials together, response rates were significantly higher with CCT than with MP (60.0% v 53.2%; P < .00001, two-tailed). There was no evidence of any difference in mortality between CCT and MP, with a nonsignificant 1.5% reduction in death rate in favor of CCT (P = .6, two-tailed). There is heterogeneity of design between the trials, but subgroup analyses by type of CCT or by dose-intensities of CCT, of melphalan, or of prednisone did not identify any particular forms of therapy t...
Introduction: Prior research on physician and non-physician endotracheal intubation (ETI) of pedi... more Introduction: Prior research on physician and non-physician endotracheal intubation (ETI) of pediatric patients demonstrates highly variable success rates. To assess the performance of a single children's critical care transport team (CCT), we analyzed data from 2.5 years of pediatric ETI encounters. Methods: A retrospective review encompassed pediatric ETI encounters from 127 patient charts from the rotorcraft and ground emergency CCT of a large quaternary referral children's hospital with an average of greater than 5000 patient transports annually. Pediatric patients were cared for by the CCT between January 1, 2011, and July 31, 2013. We included all patients between 1 day and 20 years of age in our analysis, without exclusion. A single ETI attempt was defined by the insertion of a laryngoscope. We characterized first-attempt intubation success and overall intubation success with descriptive statistics and calculated 95% confidence intervals. Results: For our cohort, demo...
Background: African-American youth carry the highest burden of HIV-infection in the US. Understan... more Background: African-American youth carry the highest burden of HIV-infection in the US. Understanding adolescent and young adult (AYA) perspectives on HIV transmission risk may serve as an important framework for targeted interventions and improved access. Methods: We conducted exploratory qualitative focus groups and quantitative surveys with HIV-infected and uninfected youth, ages 18-24 years, from Metropolitan Atlanta. Audio Computer-Assisted Self-Interviewing surveys gauged potential risk factors for HIV acquisition using categorical, and Likert scale (LS) responses (1-10). We examined perceptions regarding HIV-education and contributors to HIV-transmission. Results: Of 68 participants, 85% were male, 90% were African-American, 68% were HIV-infected, and 50% had high school education or less. Participants had a mean age of 21.5 years (SD: 1.8 years). Risk factors for HIV acquisition included high rates of unprotected sex (LS mean: 8.0) with personal preference (63%) and fear of ...
Background: Half of the 19 million new sexually-transmitted infections (STIs) and 26% of all new ... more Background: Half of the 19 million new sexually-transmitted infections (STIs) and 26% of all new HIV infections each year in the United States occur in youth 13-24 years of age. Co-STIs are a risk factor for HIV acquisition and transmission, but there are a lack of data to assess treatment and virologic control of HIV as an intervention for reducing STI transmission. Methods: This was a single-centered, retrospective analysis of HIV-infected sexually-active adolescents and young adults from January 2009 to December 2011, designed to compare incidence of STIs among patients with controlled and uncontrolled HIV and identify associated risk factors. Controlled HIV infection was defined as a 2-year mean HIV-RNA viral load of <500 copies/ml and CD4+ T-cell count >200 cells/mm3. Socio-demographic, sexual history, substance abuse and HIV variables were evaluated. Results: Of the 206 enrolled subjects, 59% were male and 92% were African American with a mean age of 21 years (2.1 SD). 6...
We reviewed the records of 98 consecutive patients, 18 years of age or younger, with pathological... more We reviewed the records of 98 consecutive patients, 18 years of age or younger, with pathologically confirmed supratentorial astroglial neoplasms at the Children&amp;amp;amp;amp;#39;s Hospital, Boston, to evaluate the importance of seizures in their presentation and natural history. Tumors were diagnosed using the WHO criteria as pilocytic astrocytomas, astrocytomas, anaplastic astrocytomas, glioblastomas, giant cell glioblastomas, oligoastrocytomas and gangliogliomas. Our results were as follows. (1) Fifty percent of children had seizures as part of their presentation and 30% had seizures as their only presenting phenomenon. (2) The seizures varied in nature, but complex (55%) or simple (28%) partial seizures were by far the most common types, occurring in 77% of cases. (3) Preoperative electroencephalography (EEG) accurately lateralized to the tumor side in 88% of the cases and localized to the correct lobe in 56%. (4) Tumors involving cerebral cortex significantly correlated with seizures at presentation as compared to noncortical locations; 59% of patients with cortical tumors presented with seizures, and only 15% of patients with noncortical tumors experienced seizures. Lesions in the temporal and frontal lobes had the highest incidence of seizures. (5) Patients with gangliogliomas and oligoastrocytomas had the highest incidence of seizures, 88 and 86%, respectively, whereas patients with anaplastic astrocytoma had the lowest incidence, 21%. (6) Histopathologic calcification was associated with seizures at presentation approaching significance (p = 0.06). (7) Seizures at presentation were significantly associated with good prognosis (p = 0.02).
Thirty-three evaluable patients with Hodgkin&amp;amp;#39;s disease who failed radiotherapy we... more Thirty-three evaluable patients with Hodgkin&amp;amp;#39;s disease who failed radiotherapy were treated on this phase II study with bleomycin, lomustine, cyclophosphamide, vincristine, procarbazine and prednisone given every 28 days for a minimum of eight courses. Twenty-five patients (76%; 95% CI=55.6-87.1%) achieved a complete remission, the median duration of which cannot yet be determined, but the probability of remaining in continuous complete remission at 10 years is.64. The median survival from entry on this study for all evaluable patients is 10 years, and 12 patients were alive at the time of this analysis with a median follow-up for them of 15.5 years. Of the 22 patients who died, 11 died of progressive or recurrent Hodgkin&amp;amp;#39;s disease and 11 died of other causes including 7 second primary neoplasms and at least one myocardial infarction. Both are now well known late complications of Hodgkin&amp;amp;#39;s disease treatment.
Adrenal insufficiency may be common in adults and children with vasopressor-resistant shock. We d... more Adrenal insufficiency may be common in adults and children with vasopressor-resistant shock. We developed a protocolized approach to low-dose adrenocorticotropin testing and empirical low-dose glucocorticoid/mineralocorticoid supplementation in children with systemic inflammatory response syndrome and persistent hypotension following fluid resuscitation and vasopressor infusion. We hypothesized that absolute and relative adrenal insufficiency was common in children with systemic inflammatory response syndrome requiring vasopressor support and that steroid administration would be associated with decreased vasopressor need. Retrospective review of pediatric patients with systemic inflammatory response syndrome and vasopressor-dependent shock receiving protocol-based adrenocorticotropin testing and low-dose steroid supplementation. The incidence of absolute and relative adrenal insufficiency was determined using several definitions. Vasopressor dose requirements were evaluated before, and following, initiation of corticosteroids. Seventy-eight patients met inclusion criteria for systemic inflammatory response syndrome and shock; 40 had septic shock. Median age was 84 months (range, 0.5-295). By adrenocorticotropin testing, 44 (56%) had absolute adrenal insufficiency, 39 (50%) had relative adrenal insufficiency, and 69 (88%) had either form of adrenal insufficiency. Adrenal insufficiency incidence was significantly higher in children &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;2 yrs (p = .0209). Therapeutic interventions included median 80-mL/kg fluid resuscitation; 65% of patients required dopamine, 58% norepinephrine, and 49% dopamine plus norepinephrine. With steroid supplementation, median dopamine dose decreased from 10 to 4 μg/kg/min at 4 hrs (p = .0001), and median dose of norepinephrine decreased from 0.175 μg/kg/min to 0.05 μg/kg/min at 4 hrs (p = .039). Absolute and relative adrenal insufficiency was prevalent in this cohort of children with systemic inflammatory response syndrome and vasopressor-dependent shock and increased with age. Introduction of steroids produced a significant reduction in vasopressor duration and dosage. Use of low-dose adrenocorticotropin testing may help further delineate populations who require steroid supplementation.
Mechanoreceptor and noxious thermal inhibitory stimulation modulate pain conduction but have not ... more Mechanoreceptor and noxious thermal inhibitory stimulation modulate pain conduction but have not been clinically tested in combination. Our objectives were to determine whether a vibrating cold device decreased adult venipuncture pain on a 10 cm visual analog scale more than no intervention, and compared with vapocoolant analgesia versus no intervention. The design was a prospective randomized crossover clinical trial. Thirty healthy adult volunteers were randomized to the study device or vapocoolant intervention. One nurse attempted cannulation on both intervention and control hands with a 22 gauge intravenous catheter. Vapocoolant was applied to the cannulation site, or the device was applied 5 to 10 cm proximally throughout the intervention attempt. Visual analog scale assessed needle fear and the primary outcome of self-reported pain. Sixteen device and 14 vapocoolant participants were included in this study. One participant felt discomfort from device prongs before the needle stick and was excluded. Compared with no intervention, the device reduced pain significantly (mean 9.9 mm, 95% confidence interval 0.82-19, P=0.035, SD 16) whereas vapocoolant did not (mean 7.9 mm, 95% confidence interval -1.8-17.7, P=0.1, SD 16.9). Mean pain reduction for device group participants was not significantly different from vapocoolant participants. Each 20 mm of prior anxiety increased the likelihood of intervention pain relief (odds ratio 2, P=0.043). One venipuncture failure occurred in the vapocoolant intervention. The combination of cold and vibration gave significant venipuncture pain relief without affecting cannulation success. Interventions were more helpful for those with greater preprocedural fear. Larger sample sizes and a prongless device could better compare equivalence or superiority to existing pain relief modalities.
Uploads
Papers by traci leong